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* 1. Do we have permission to share this exemplar, your organizations information, and your contact information with other organizations and to publish this exemplar in our database for public use?

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* 2. Contact Information

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* 3. Are you the author or responsible party with authority to submit this exemplar?

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* 4. For what Grade Level is this exemplar?

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* 5. What discipline(s) does your exemplar represent? [check all that apply]

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* 6. What type of document is this exemplar?

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* 7. What type of curricula or tool is your exemplar? [check all that apply]

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* 8. Select the Big Idea(s) that applies to your exemplar [choose top 3]

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* 9. Select the Higher Order Thinking Skills that apply to your exemplar [choose top 3]

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* 10. Select the Applied Knowledge domains that apply to your exemplar [choose top 3]

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* 11. Select the Dispositions that apply to your exemplar [choose top 3]

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* 12. Select the Applications and Actions that apply to your exemplar [choose top 3]

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* 13. Select the Community Connections attributes that apply to your exemplar [choose top 3]

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* 14. Why was this exemplar designed (rationale)?

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* 15. What was the context in which this piece of work was designed?

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* 16. Do you have results - student work samples with assessment(s) and performance criteria?

If yes, please attach those documents at the bottom of this form and continue to Question 18 to check which attributes this student work is evidence of.

If no, would you be willing to collect and submit student work samples with assessment(s) and performance criteria at a later date? Skip to Question 19.

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* 17. This student work is evidence of which EfS attribute(s) - from your selections above

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* 18. What challenges did you face in designing and/or implementing this piece of work? How did you overcome them? What did you learn as a result? What would you/will you change?

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* 19. What ways can this exemplar be adapted for other uses?

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* 20. Does this exemplar require any prior knowledge to be effective? 

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* 21. Upload Exemplar

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* 22. Upload Assessment(s)

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* 23. Upload Student Work Samples

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* 24. Upload Performance Criteria

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